Marlene Busko

April 30, 2014

TORONTO, ON — Although European guidelines recommend that cases of patients with severe CAD should be discussed by a "heart team" consisting of a cardiac surgeon, an interventional cardiologist, and a noninterventional cardiologist, a study of three hospitals in London found that this step is often skipped[1].

The joint European Society of Cardiology and European Association for Cardiothoracic Surgery (ESC/EACTS) guidelines issued in August 2010 suggest that patients with left main stem disease, proximal left anterior descending disease, or three-vessel coronary disease should be discussed for possible CABG prior to elective PCI, Dr Martin T Yates (St George's Hospital, London, UK) said here at the American Association for Thoracic Surgery 2014 Annual Meeting .

However, their study showed that two years after publication of the joint ESC/EACTS guidelines, "elective PCI is [still] performed in a significant number of patients with severe coronary artery disease without discussion by the heart team or with a cardiac surgeon." These findings reflect myocardial revascularization "practice across London hospitals and most likely the whole of the United Kingdom," he said.

"Perhaps of most concern, and I guess surprisingly, between 80% and 90% of patients undergoing elective PCI for three-vessel coronary disease never discussed with a cardiac surgeon are incompletely revascularized," he noted. "We all know that there are significant data coming out that incomplete revascularization—both percutaneous intervention and surgical revascularization—has a negative impact on outcomes, both early and late," he said.

"We feel that further action is required so that patients with severe coronary artery disease receive optimal revascularization," he concluded.

Additional Follow-up?p

Previously, the group reported that heart-team discussions were not occurring one year after the guidelines had been issued[2].

This study extends this work. Using the British Cardiovascular Intervention Society database, the researchers identified all patients undergoing elective revascularization at three centers in London during two six-month periods before and after the guidelines were issued: January to June 2010 and January to June 2012.

In the 2010 time period, of 621 elective PCIs, 224 (36%) were for patients with severe CAD. The numbers remained virtually identical two years later. In the 2012 time period, of 686 elective PCIs, 275 (40%) were for patients with severe CAD.

Among the patients with severe CAD, three-quarters had proximal left anterior descending disease, about one-fifth had three-vessel coronary disease, and a small number had left main stem disease.

In both 2010 and 2012, 83% of the cases of patients with severe CAD who underwent elective PCI had not been first discussed with a surgeon. The patients were about 65 years old. About one-third had previously undergone PCI, and a minority had diabetes.

A Failed Concept?

The "study reveals the failure of the 'heart-team' concept in discussing patients who are suitable for either therapy; I think that's true in many instances in the United States certainly as well," the assigned study discussant, Dr Robert A Guyton (Emory University, Atlanta, GA), said.

However, "there are no data [apart from consensus opinion] supporting the benefit of the 'heart-team' concept," he pointed out. "I would encourage you and others to look for a statistically significant number needed to treat" to show a benefit for having vs not having a heart-team discussion, in a larger group of patients over a longer time period, he suggested.

"The European guidelines don't make a major distinction between revascularization for survival benefit and revascularization for relief of symptoms," Guyton commented to heartwire after the talk.

"In [the US], we've been very clear," he continued. "Survival benefit is superior with surgery, whereas relief of symptoms can be equivalent with the two [procedures]. So in early coronary disease, PCI and surgery are relatively equal, but in more advanced coronary disease involving multiple vessels, there is a big difference in survival between surgery and PCI. That's why the heart-team discussion is a patient benefit," so patients can make an informed choice about their treatment.

Yates had no disclosures to report. Guyton is on the valve advisory board for Medtronic.

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